Laserfiche WebLink
N , + APPLICATION FOR PERMIT • <br /> \O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LL*- 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT <br /> SAN JOAQUIN LOCAL HEALTH DISTRITE Telephone 12091 466-6781 RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION_ RMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> SPECIAL PERMIT (Complete in Triplicate) SEP 121988 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t rr� a r,bed. This application is. <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t e u aha +kqALdWn Joaquin <br /> Local Health District. RMIT SERVICES <br /> Job Address <br /> City JJ <br /> 7C 'Lot Size [(/ PM <br /> 7(�,�, 1 (/ <br /> Owner's Name <br /> �jL /� ''rU'mS {AAddress / J /.- ///'fc r�.����aPhone <br /> Contractor /C.G L%fG-/A -t7r3 �%L[<'��Address 4e__14 �tO4f�f f - License <br /> TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT ❑ DE <br /> PUMP INSTALLATION ;;I- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 2f _ SEWER LINES ZL r-1 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE T NS <br /> AFT'Inclustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private eF-! Gravel 1Pack_ CI Tracy Type of Casing G Specifications <br /> VI Public /17 Othe/RO/t[rf1N fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumpS[i{t'-%I— H.P. _..� _ State Work Done — `•� <br /> Well Destruction 0 Well Diameter• _ Sealing Material (top 50') <br /> Depth _ Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial__ Other <br /> Number of living units: _ Number of bedrooms_- <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must for air requi_edinspections. Complete drawing on rev se side. r) <br /> Signed X Date: <br /> FOR DEPARTMENT USE ONLY 9 <br /> Application Accepted by Date I —2/—V 0Q'p <br /> Area <br /> Pit or Grout Inspection by //rte/ Data ��JFinall Inspection by z� A Date <br /> Additional Comments: _ //✓[_,Z i"Y-L1°6ny a&j- z Z",tCN C/®4 O-O/TK <br /> O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stir., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED }CK RECEIVED BY DATE PERMIT'NO. <br /> SEH 1:3.24(REV vxs) -` <br />